By the mid-1900’s, heart disease was the leading cause of death in the U.S, with autopsies revealing coronary atherosclerosis as the culprit (Dalen, Alpert, Goldberg, & Weinstein, 2014). Diets in the United States were consisting of more sugar and animal fats, and smoking was on the rise while physical activity was diminishing. In addition, the 1900’s brought about the popularity of fast food restaurants, hydrogenated vegetable oils, and convenience foods. It wasn’t until the 1950’s that the relationship of diet and CVD was postulated by Ancel Keys, who observed that Mediterranean and Japanese populations with low fat diets had less heart disease (Story, 2018). More recent studies confirmed that populations eating diets lower in saturated fat and animal protein, and high in grains, vegetables, and fruits, had less heart disease (Campbell & Campbell II, 2006, p. 116). But when these same populations moved to higher risk areas and adopted more Western diets, their heart 3 disease rates dramatically increased (Greger, 2015, p. 19). Over the years, many studies have been done on CVD, and treatments that control (but don’t cure) CVD have been developed. Promotion of diet and lifestyle changes, as well as modern treatments have slowed the number of deaths from CVD, but it continues to be the top health issue in the U.S. (Dalen, Alpert, Goldberg, & Weinstein, 2014).
Cardiovascular disease involves the blood vessels of the heart, specifically the coronary arteries. It falls under the umbrella of heart disease and is the cause of myocardial infarctions (MI) and angina (chest pain). When the heart muscle is damaged from infarction, heart failure and dysrhythmias may develop. CVD may not manifest with symptoms for years as the damage develops; yet other areas of the body may demonstrate vascular problems in the form of erectile dysfunction, strokes, and peripheral artery disease. Autopsies from accidental deaths in children have shown that atherosclerosis (fatty deposits in the arteries that lead to CVD) was developing in most of the children under 10 years old (Greger, 2015, p.21). This is grim news, suggesting that the roots of CVD can begin as early as childhood.
There are several diseases and modifiable risk factors for
developing CVD. These include hypertension (HTN), high blood cholesterol (total cholesterol over 200 milligrams per deciliter (mg/dL), low density lipoprotein (LDL) over 100 mg/dL, and triglycerides over 150 mg/dL), high density lipoprotein (HDL) under 40 mg/dL, diabetes, chronic stress, elevated homocysteine levels over 12 micromoles per liter (mmol/L), obesity, sedentary lifestyle, and smoking cigarettes (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007, p. 787- 788). Non- modifiable risk factors include age, gender, and genetics.
Medications are used extensively to manage CVD and its commonly associated risk factors. These include statins to lower cholesterol, aspirin to decrease blood clotting, fibrinolytics when angioplasty is not available, opioids and nitroglycerin for chest pain, anti-diabetic agents to control blood sugar, and a variety of antihypertensives or diuretics to control blood pressure. If patients develop arrhythmias, they may also be put on antiarrhythmics and blood thinners, and/or require pacemakers.
These medications all have side effects, including fatigue, electrolyte imbalances, orthostatic hypotension, symptomatic bradycardia or heart blocks, gastrointestinal disturbances, dizziness, ototoxicity (loop diuretics), heart failure, hepatic toxicity, renal failure, muscle damage (statins), and gastric bleeding or hemorrhagic strokes (anticoagulants and anti-platelets) (Lewis et al, 2007, p. 774-776).
Procedures to treat CVD include coronary angioplasty (stenting stenosed coronary arteries) and CABG. Some patients with severe heart failure from advanced CVD damage may need heart transplants; after extensive wait times, they may not survive. Patients are generally encouraged to lose weight, exercise more, and quit smoking. Some doctors may recommend the low-fat Mediterranean diet, a low sodium diet, or the Dietary Approaches to Stop Hypertension (DASH) diet, but many patients report no dietary guidance from their physicians.
Plant-based, low-fat diets have demonstrated in numerous studies the ability to halt and, in some cases, reverse CVD, as well as improve co-morbidities and symptoms. A plant-based diet is defined as a diet in which the majority of calories are obtained from plants (vegetables, fruits, grains, legumes, nuts, and seeds); most studies on plant-based diets are actually vegan (no animal products ingested at all) or vegetarian (no meat or fish). Plant-based diets are more effective than other “heart healthy” diets like the Mediterranean diet or DASH diet because patients following a plant-based diet have less adverse cardiac events. A study in 2014 conducted by Dr. Caldwell Esselstyn on 198 patients with advanced CVD demonstrated a “30-fold difference” in cardiac event incidence in patients following a whole food, plant-based diet versus those patients from the Mediterranean-diet-based Lyon Diet Heart Study (Esselstyn, 2017).
Plant-based diets can decrease the need for medications. While most patients with angina reach for nitroglycerin to treat their chest pain, Dr. Ornish discovered that his patients eating a plant-based diet were able to reduce their incidence of angina pain by 91% after one year, versus the control group which had a 186% increase in angina frequency (Ornish, et al., 1998). In another study from 2006, following a vegan diet allowed 43% of diabetic patients to reduce their medication requirements (Tuso, Ismail, Ha, & Bartolotto, 2013). Given the large amount of side effects from medications used to treat CVD, not to mention the chronic expense of medications, enabling patients to decrease or get off medications is a priority. It is apparent that diet can have a profound impact on CVD symptoms and co-morbidities without the side effects or risk factors of commonly used medications.
There are several factors to consider that make a plant-based diet so effective against CVD. These factors include high mineral and fiber content, healthy plant fats versus saturated animal fats, the naturally low-fat nature of most plant foods, and the high antioxidant content of plant foods that decreases inflammation:
- Minerals and Fiber: Plants are high in
antioxidants, vitamins, minerals, and fiber.
Plants are high in potassium and magnesium, which lower blood pressure by enhancing endothelial health and acting as natural vasodilators (Barnard et al., 2009, 280- 281). Unprocessed plant foods are low in sodium, decreasing the 9-17% risk of sodium-induced hypertension (Barnard et al, 2009, p. 280). Fiber assists the body in binding dietary fats and cholesterol and eliminating them through the stool. It also keeps blood sugar from rising suddenly after a meal, decreasing the risk of developing insulin resistance. High fiber foods are more filling, and more satiety means less overeating and less weight gain.
- Heart Healthy Plant Fats: While nuts, seeds, and avocados were not included in the studies and dietary recommendations by Dr. Esselstyn, these foods are important parts of a plant-based diet, and contain heart-protective nutrients including magnesium, fiber, vitamin E (a powerful 25 antioxidant), omega-3 fatty acids (anti- inflammatory), monounsaturated fats, L-arginine, and plant sterols. Servings of 1-3 of nuts per day in clinical trials reduced total cholesterol by 2-16% and LDL by 2-19% (Bernard et al., 2009, p. 271). A study of over 61,000 Swedish people and their nut consumption over 17 years revealed an inverse relationship between nut consumption and MI, heart failure, and atrial fibrillation (Larson, Drca, Bjorck, Back, & Wolk, 2018). Avocado intake has been associated with increased HDL, suggesting that it may assist the body in clearing excess lipids from the blood and therefore benefit cardiac health (Mahmassani, Avendano, Raman, & Johnson, 2018). Because nuts and avocados are high in fats, patients with severe CVD or those trying to lose weight should limit their consumption to one serving per day.
- Antioxidants: High antioxidants in a plant-based diet decrease the oxidation of LDL and the overall burden of free radicals on the cardiovascular system. Antioxidants also improve nitric oxide production by the endothelium (Barnard et al, 2009, p. 257). Free radicals and oxidative burden play a role in CVD risk, according to a study that evaluated how heavy metals contribute to coronary and vascular heart disease, high blood pressure, and heart attacks.
The evidence that dietary changes can improve CVD is indisputable. While both DASH and Mediterranean diets can improve the disease, a plant-based diet has the most lasting and dramatic effects on reversal of disease, halting progression, and eliminating symptoms. The benefits of a plant-based diet are not limited to the heart; it also improves or eliminates co-morbid risk factors or diseases such as type II diabetes, obesity, dyslipidemia, and hypertension. The protective nutrients found in a plant-based diet have powerful effects on the pathophysiology of CVD, primarily by reducing oxidative stress and inflammation and enhancing endothelial function. Based on the plethora of studies that support plant-based diets as a treatment or adjunct for CVD improvement, all patients with CVD or co-morbid risk factors and diseases should be educated early on about adopting this diet. Furthermore, public health organizations should educate the general public about preventing CVD, hypertension, high cholesterol, diabetes, and obesity by using a plant-based diet and other lifestyle changes.
About the Author
Eden Huma, RN is a 2020 graduate of Hawthorn University’s Master of Science in Holistic Nutrition program. She is a registered nurse who has spent countless hours working in emergency medicine both in ERs and on mobile ambulance teams. Having a strong nutrition influence since childhood, she has a passion for plant- based eating and the preventive aspect of nutrition on health and disease states. She runs the website www.nurseinthekitchen.com.
Barnard, N.D., Weissinger, R., Jaster, B.J., Kahan, S., & Smyth, C. (2009). Nutrition Guide for Clinicians. (2nd Ed.) Washington DC: Physicians Committee for Responsible Medicine.
Campbell, T.C. & Campbell II, T.M. (2006). The China Study: Startling Implications for Diet, Weight Loss, and Long-Term Health. Dallas, TX: Benbella Books, Inc.
Dalen, J.E., Alpert, J.S., Goldberg, R.J., & Weinstein, R.S. (2014). The epidemic of the 20th century: coronary heart disease. American Journal of Medicine, 127(9): 807-812.
Esselstyn, C.B. (2017). A plant-based diet and coronary artery disease: a mandate for effective therapy. Journal of Geriatric Cardiology, 14(5):317-320.
Greger, M. (2015). How Not to Die: Discover the Foods Scientifically Proven to Prevent and Reverse Disease. New York, NY: Flatiron Books.
Larsson, S.C., Drca, N., Bjorck, M., Back, M., Wolk, A. (2018). Nut consumption and incidence of seven cardiovascular diseases. Heart, 104:1615-1620.
Lewis, S.L, Heitkemper, M.M, Dirksen, D.R, O’Brien, & P.G, Bucher, L. (2007). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (7th ed). St. Louis, MI: Mosby Elsevier.
Mahmassani, H.A, Avendano, E.E., Raman, G., & Johnson, E.J. (2018). Avocado consumption and risk factors for heart disease: a systematic review and metaanalysis. The American Journal of Clinical Nutrition, 107(4):523-536.
Ornish, D., Scherwitz, L.W., & Billings, J.H.,Gould, K.L., Merritt, T.A, Sparler, S., Armstrong, W.T, Ports, T.A., Kirkeeide, R.L., Hodgeboom, C., & Brand, R.J.
(1998). Intensive lifestyle changes for reversal of coronary heart disease. Journal of the American Medical Association, 280(23):2001-2007.
Story, C.M. (2018, Sept. 21). The history of heart disease. Healthline. Retrieved from https://www.healthline.com/health/heart-disease/history
Tuso, P.J, Ismail, M.H., Ha, B.P., & Bartolotto, C. (2013). Nutritional update for physicians: plant-based diets. The Permanente Journal, 17(2):61-66.